Safety and efficacy of tubeless percutaneous nephrolithotomy in patients on anti-platelet therapy and cirrhotic patients

The safety of continued low dose aspirin therapy during Complete Supine Percutaneous Nephrolithotomy (csPCNL)

OBJECTIVE

Using anticoagulants and antiplatelet drugs in patients with cardiovascular and medical comorbidities is prevalent. Because of hyper vascular nature of kidney, physicians tend to stop using aspirin before percutaneous nephrolithotomy (PCNL). We have shown the effects of remaining on low dose aspirin in complete supine PCNL (csPCNL).

MATERIAL AND METHODS

The records of 643 patients who underwent csPCNL between 2012 and 2018 were analyzed. Surgical outcomes and complications of patients who were on aspirin therapy and continued it daily (group A) were compared with those not taking aspirin (group B).

RESULTS

Of the 643 csPCNLs, 40 (6%) were performed in patients of group A and the rest of 603 (94%) cases were in group B. The differences between the mean age of groups were statistically significant (60.08±9.45, group A and 48.66±12.32, group B) (P<0.001). Thirty-nine (97.5%) of patients in group A and 548 (90.9%) of group B were stone free by the end of the study which was not statistically significant (P=0.118). The mean operative time between groups A and B (43.20±21.37 and 44.83±16.83, respectively) was not considered significant (P=0.561). There was also no significant difference between 2 groups in any types of complications. Multivariate analysis showed that, perioperative aspirin use was not a significant predictor of transfusion, Hb drop, operative time and other complications.

CONCLUSIONS

Remaining on aspirin does not increase the risk of bleeding, transfusionand other complications. Consequently, continuing aspirin prioperatively in csPCNL appears safe. There is no fear for continuing aspirin in csPCNL.

LEVEL OF EVIDENCE

3.

Percutaneous nephrolithotomy during uninterrupted aspirin therapy in high-cardiovascular risk patients: preliminary report

OBJECTIVE

To determine the feasibility and safety of performing percutaneous nephrolithotomy (PCNL) in high-cardiovascular risk patients remaining on aspirin therapy.

METHODS

We retrospectively reviewed all PCNLs performed by 3 fellowship-trained endourologists at a single institution between July 2012 and January 2014. All patients remaining on aspirin for imperative indications through the day of surgery were evaluated for surgical outcomes and thromboembolic events.

RESULTS

Of 281 PCNL procedures performed during the study period, 16 (5.7%) were performed in 14 patients taking aspirin, uninterrupted, through surgery. Mean surgery time was 66 minutes, mean estimated blood loss was 161 mL, and mean length of hospital stay was 2.8 days. All patients were stone free. There were no intraoperative complications. A total of 5 patients experienced a postoperative complication (n = 4, Clavien grade II; n = 1, Clavien grade IIIa). No patient experienced a perioperative thromboembolic or cardiac event. Three patients required a blood transfusion postoperatively, and none experienced delayed renal bleeding.

CONCLUSION

PCNL can be performed safely and effectively in high-cardiovascular risk patients continuing aspirin perioperatively. Compared with the potential sequelae of a thromboembolic or cardiac event, PCNL is associated with an acceptably low transfusion rate, and should be considered a viable treatment option for large renal stones in this population.

Tubeless percutaneous nephrolithotomy: outcomes with expanded indications

INTRODUCTION

Tubeless PCNL has been utilized to shorten hospital stay and improve patient postoperative pain control. Prior studies have excluded those patients with significant bleeding or other complications. Our objective was to evaluate the utility of tubeless PCNL in all patients irrespective of intraoperative outcome.

MATERIALS AND METHODS

A retrospective review of the charts of patients who underwent PCNL at our institute was performed. Patients were assigned to one endourologist Who routinely performed tubeless PCNL and to a second endourologist who routinely left a small-bore pigtail nephrostomy. Preoperative demographics operative and postoperative outcomes were compared.

RESULTS

Out of 159 patients included, 83 patients had tubeless PCNL while 76 patients had standard PCNL. There was no difference between groups regarding age, gender, ASA score, number, maximum diameter of stones, number of calyces involved, Stone density (HU), laterality and use of preoperative narcotics. While staghorn stones were more common in patients who underwent standard PCNL (p = 0.008). Tubeless patients had less number of access tracts (p ≤ 0.001), shorter hospital stay (1.7 vs. 3.0 days, p = 0.001) when compared to standard PCNL group. Multivariable analysis controlling for confounding factors including staghorn calculi and number of accesses confirmed that tubeless PCNL was associated with shorter hospital stay and less postoperative pain. There was no significant difference in complication rates between the two groups.

CONCLUSION

Our report confirms the previous reports of shorter hospital stay, less pain and analgesia as compared to standard PCNL, and establishes its safety irrespective of bleeding, perforation, extravasation or other intraoperative issues that have previously been utilized as exclusionary criteria for this approach.